PROJECT SUMMARY Neuropsychiatric symptoms (NPS) eventually affect >90% of people who live with Alzheimer?s Disease and related dementias (ADRD): they reduce patients? and caregiver?s quality of life, are difficult to manage, and often prompt decisions for institutional placement. Antipsychotic medications were commonly used until evidence emerged linking these medications to increased risk of stroke and death. Recent federal efforts to reduce unnecessary harm from long-term antipsychotic exposure include nursing home (NH) quality reporting requirements under the Affordable Care Act (ACA) and the National Partnership to Improve Dementia Care in Nursing Homes Centers (both in 2012). Since 2011, antipsychotic exposure has declined by 31.8% in nursing homes. The ACA/Partnership focused only on people with ADRD living nursing homes, but the majority of people with ADRD reside in settings other than nursing homes, where NPS are also common but there is less oversight over medication exposures. Our central hypothesis is that while federal initiatives led to reduced antipsychotic use in the NH, trade-offs toward greater exposure to other psychoactive medications may have limited the anticipated net health effects, and that racial and ethnic minorities face a differential burden of the consequences of psychotropic exposure. Our approach entails analyzing national Medicare data, including medications, individual characteristics, and clinical outcomes, over a decade (2007-2017). The specific aims will evaluate substitution of other psychotropic medications for antipsychotics in NH residents; the impact of federal antipsychotic initiatives on assisted living and community dwellers; racial/ethnic differences in exposures across settings; and their effect on mortality, stroke, major fractures and psychiatric admissions. Using novel approaches developed by the P01 Data Management and Methods Core, we will assess important policies intended to reduce the adverse outcomes of antipsychotics in older adults with ADRD across care settings and among minorities with potential to guide further policy refinement as necessary.